Parkinson’s Disease Parkinson’s Disease (PD) • Chronic, progressive neurodegenerative disorder characterized by • Tremor at rest • Rigidity • Akinesia/bradykinesia • Postural instability • Usually gradual and insidious Etiology and Pathophysiology • Exact cause of PD unknown • Possibly a result of a complex interplay between environmental factors and the person’s genetic makeup • Family history in 15% of cases • Increased risk with: • Post menopausal not on estrogen replacement • Low folate levels • Head traumas Etiology and Pathophysiology Parkinsonism • Many forms of secondary (atypical) parkinsonism exist • Exposure to chemicals • Drug-induced • Prescribed • Illicit • Others Etiology and Pathophysiology • Lack of dopamine (DA) • Degeneration of dopamine-producing neurons in substantia nigra of midbrain • Disrupts dopamine-acetylcholine balance in basal ganglia • Essential for normal functioning of extrapyramidal motor system Nigrostriatal Disorder Substantia nigra https://www.youtube.com/watch?v=ARdGaE1sbBM Dopamine Disorder in Parkinson’s Disease Etiology and Pathophysiology Parkinson’s Disease • Lewy bodies • Unusual clumps of protein • Found in brains of patients with PD • Unknown cause • Presence indicates abnormal brain functioning • Lewy body dementia Clinical Manifestations Parkinson’s Disease • Beginning stages • Mild tremor, slight limp, ↓ arm swing • Later stages • Shuffling, propulsive gait with arms flexed, loss of postural reflexes • 90% experience hypokinetic dysarthria (speech abnormalities) Clinical Manifestations Parkinson’s Disease • Tremor • Often first sign • Initially minimal • More prominent at rest • Aggravated by • Emotional stress • ↑ Concentration Clinical Manifestations Parkinson’s Disease • Pill rolling hand tremor • Diaphragm, tongue, lips, jaw may be involved • Essential tremor is not associated with PD • Occurs during voluntary movement, has more rapid frequency, is familial Clinical Manifestations Parkinson’s Disease • Rigidity • ↑ Resistance to passive motion when limbs are moved through their ROM • Cogwheel rigidity • Jerky quality • Like intermittent catches in passive movement of a joint Clinical Manifestations Parkinson’s Disease • Rigidity • Sustained muscle contraction • Elicits the following • Complaint of soreness • Feeling tired and achy • Pain in the head, upper body, spine, or legs • Slowness of movement Clinical Manifestations Parkinson’s Disease • Akinesia • Absence or loss of control of voluntary muscle movements • Bradykinesia • Slowness of movement • Particularly evident in the loss of automatic movements Clinical Manifestations Parkinson’s Disease • Loss of automatic movements occur subconsciously and result in classic characteristics of a person with PD • Stooped posture • Masked face • Drooling • Festination (shuffling gait) Appearance of Patient with PD Clinical Manifestations Parkinson’s Disease • Nonmotor symptoms • Depression and anxiety • Apathy • Fatigue • Pain • Urinary retention and constipation • Erectile dysfunction • Memory changes Clinical Manifestations Parkinson’s Disease • Sleep problems are common • Difficulty staying asleep • Restless sleep • Nightmares • Drowsiness during the day • REM behavior disorder • Violent dreams • Potentially dangerous motor activity during REM sleep Complications Parkinson’s Disease • Complications ↑ as disease progresses • Motor symptoms • Weakness • Akinesia • Neurologic problems • Neuropsychiatric problems • Dementia often results • Associated with ↑ mortality Complications Parkinson’s Disease • Dysphagia may result in malnutrition or aspiration • General debilitation may lead to pneumonia, UTIs, and skin breakdown • Orthostatic hypotension • ↑ Risk for falls and injuries https://www.youtube.com/watch?v=lZMFNYgnCJU Diagnostic Tests Parkinson’s Disease • No specific tests exist • Diagnosis based on history and clinical features • Requires presence of TRAP • Asymmetric onset • Confirmation is a positive response to antiparkinsonian drugs PET Scan in Parkinson’s Disease Case Study (@Jupiterimages/Comstock/Thinkstock) • 67-year-old M.J. presents to clinic with a tremor in his hands that is interfering with writing. • He also complains of muscle aches and excessive drooling saliva that he cannot swallow. • He doesn’t remember when all this began—says it was “a while ago.” Case Study (@Jupiterimages/Comstock/Thinkstock) • Physical examination reveals: • Rigidity in limbs • Shuffling gait • Blank expression • Pill rolling in both hands • M.J. is diagnosed with Parkinson’s disease. Case Study (@Jupiterimages/Comstock/Thinkstock) • He is anxious and worries that his tremors will never stop. • What can you tell him? Interprofessional Care • No cure for PD • Interprofessional care is aimed at symptom management Interprofessional Care Drug Therapy • Aimed at correcting imbalances of neurotransmitters within the CNS • Antiparkinsonian drugs either • Enhance or release supply of DA • Antagonize or block the effects of overactive cholinergic neurons in the striatum Interprofessional Care Drug Therapy • Levodopa with carbidopa (Sinemet) is the primary treatment • Precursor of DA • Can cross blood-brain barrier • Converted to DA in the basal ganglia • Carbidopa inhibits an enzyme that breaks down levodopa before it reaches brain Interprofessional Care Drug Therapy • Carbidopa/Levodopa Adverse Effects: • Nausea and vomiting • Postural hypotension • Psychosis • Dyskinesia • Drug interactions Interprofessional Care Drug Therapy • Effectiveness of Carbidopa/Levodopa could wear off after a few years of therapy • Some HCPs initiate therapy with a DA receptor agonist (pramipexole, ropinirole) • Directly stimulates DA receptors • Entacapone is added when moderate to severe symptoms develop Interprofessional Care Drug Therapy • Antiviral agent – amantadine • ↑ Dopamine release; blocks reuptake • Anticholinergics • ↓ Activity of ACh • MAO-B inhibitors • ↑ Levels of DA • Prolong half-life of levodopa Interprofessional Care Drug Therapy • Use of only one drug is preferred • Fewer side effects • Dosages are easier to adjust • Combination therapy is often required as disease progresses • Excessive dopaminergic drugs can lead to paradoxic intoxication Interprofessional Care Drug Therapy • Episodes of hypomobility • Often occur within 3-5 years • Off episodes • Combination carbidopa, levodopa, entacapone • Apomorphine (Apokyn) • Needs to be taken with an antiemetic drug Interprofessional Care • Surgical Therapy • Used in patients • Unresponsive to drug therapy • Have developed severe motor complications • DBS – Deep brain stimulation • Ablation – Destruction • Transplantation Deep Brain Stimulator Interprofessional Care • Deep Brain Stimulation • Most common surgical treatment • Reversible and programmable • ↓ Increased neuronal activity produced by DA depletion • Improves motor function • Reduces dyskinesia and medications Interprofessional Care • Ablation Surgery • Locate, target, destroy area of brain affected by PD • Destroys tissue that produces abnormal chemical or electrical impulses leading to tremors or other symptoms Interprofessional Care • Transplantation of fetal neural tissue into the basal ganglia • Provides DA-producing cells in the brains of patients • Research and clinical trials are ongoing Interprofessional Care • Nutritional Therapy • Malnutrition and constipation can be serious consequences • Patients with dysphagia and bradykinesia need food that is easily chewed and swallowed • Adequate fiber Interprofessional Care • Nutritional Therapy • Eating more numerous small meals is less exhausting than eating fewer large meals each day • Provide ample time to avoid frustration • Levodopa can be impaired by protein and vitamin B6 ingestion Case Study (@Jupiterimages/Comstock/Thinkstock) 1. What other emotional issues may M.J. have? 2. What can you tell him about treatment options? 3. What monitoring do you think should be done for him considering the manifestations of this disease? Nursing Management Nursing Assessment • Health History • Possible risk factors • Subjective Data • Objective Data Nursing Management Planning • Maximize neurologic function • Maintain independence in activities of daily living (ADLs) for as long as possible • Optimize psychosocial well-being Nursing Management Nursing Implementation • PD is a chronic degenerative disorder with no acute exacerbations • Focus teaching and nursing care • Maintenance of good health • Encouragement of independence • Avoidance of complications such as contractures and falls Nursing Management Nursing Implementation • Promote physical exercise and a well-balanced diet • Limit consequences from decreased mobility • Physical therapy • Occupational therapy Nursing Management Nursing Implementation • Problems secondary to bradykinesia can be alleviated by • Consciously thinking about stepping over a line on the floor • Lifting toes when stepping • One step back and . . .two steps forward Nursing Management Nursing Implementation • Get out of a chair by using arms and placing the back legs on small blocks • Remove rugs and excess furniture • Simplify clothing from buttons and hooks • Use elevated toilet seats • Use an ottoman to elevate legs Nursing Management Nursing Implementation • Manage sleep problems • Assist patients as they make adjustments to their lifestyle to accommodate symptoms • Caregivers may experience stress associated with disease progression (i.e., dementia) Case Study (@Jupiterimages/Comstock/Thinkstock) • • • What changes could M.J. and his wife make to his house? What other teaching should you do for M.J. and his wife? How might the disease progress? Case Study (@Jupiterimages/Comstock/Thinkstock) • M.J.’s wife tells you that she thinks he has dementia. • When you are working with a patient who has cognitive impairment, what modifications in your teaching can you make to facilitate understanding? Case Study (@Jupiterimages/Comstock/Thinkstock) Several years later you see M.J. at your outpatient clinic with a cough and fever. It is obvious that his Parkinson’s disease has advanced. During your assessment of him, you would expect to find a. slurred speech, visual disturbances, and ataxia. b. muscle atrophy, spasticity, and speech difficulties. c. muscle weakness, double vision, and reports of fatigue. d. drooling, stooped posture, tremors, and a propulsive gait. Case Study (@Jupiterimages/Comstock/Thinkstock) An appropriate nursing diagnosis for M.J. at this stage of advanced Parkinson’s disease is a. risk for injury related to limited vision. b. risk for aspiration related to impaired swallowing. c. urge incontinence related to effects of drug therapy. d. ineffective breathing pattern related to diaphragm fatigue. .
